Question

Hello. One of my patients is a lady aged 48 years. She has most signs and symptoms that correlate with hypothyroidism. Her TSH is 9.7 mlu/L ( range 0.27-4.2), T4 is 13 pmol/L (range 12-22), T3 is 4.7 pmol/L (range 2.8-7.1) . There is no relevant history. She is having menorrhagia (severe) , shortness of breath, iron deficiency anemia, obesity, lemon yellow color, flushing of checks, BP= 170/90, diabetic since one year (type 2) , had rough skin, complain always of somnolence , general weakness and sweating. Please send for me your opinion and plan for management and should we consider it as a case of overt hypothyroidism or a subclinical one.

Thanks for your cooperation.

Dr. Moh'd Attallah

Response

Dear Dr Attallah,

Your patient has still a T4 and T3 within the normal range and should therefore be classified as subclinically hypothyroid. It is difficult to assess if her complaints are due to hypothyroidism and/or to her diabetes in combination with obesity. On the other hand the level of TSH and free T4 are at the border of overt hypothyroidism and my advise to you is to determine her thyroid auto-antibodies and to treat her with thyroid hormone such that her final TSH finally drops between 0.27 and maximally 2.0 mU/l. If antibodies are present in the serum, than it is almost certain that she will eventually develop full blown hypothyroidism and in that case treatment should be continued irrespective of any immediate effect. If antibodies are absent and T4 substitution has no effect discontinuation of T4 could be considered but the patient should be frequently seen in follow up.